Friday, November 4th 2016

Summary: In this episode, I talk to two women with periods on their mind – Kiran Gandhi, who freebled the London Marathon in 2015, and Heli Kurjanen, inventor and founder of the Lunette menstrual cup. Kiran and I discuss the public and private experience of having periods, the effect of menstrual taboos on young girls, and what it means to live a life of hiding ourselves. Kiran has leveraged her fame from the London Marathon to continuing her period activism and consciousness raising across multiple platforms. Follow her on Twitter at @MadameGandhi and on her website at kirangandhi.com.

Badass Kiran Gandhi. In addition to freebleeding a marathon, she drums for MIA and Thievery Corporation and has her own musician project called Madame Gandhi. You know, NBD.

Heli and I discuss how one goes from making your own diapers for your baby to being inspired to invent and market your own brand of menstrual cups. We also discuss the environmental and ethical issues that go along with making and selling menstrual products. Lunette is doing great work for women all over the world, and I was proud to have her on as a guest. Follow Heli at @HeliK_Lunette, her product at @Lunettecup, and the Lunette cup website at lunette.com.

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Friday, June 24th 2011

What is used by 20-26% of European, 30% of Israeli, 34% of Chinese, 34% of Egyptian, and 49% of Korean women… but only 1-2% of US women (Harper et al. 2008)? The intrauterine device, or IUD! The IUD is found in two forms: the copper IUD, and the hormone-releasing IUD that releases a tiny amount of progesterone. Both make the uterus inhospitable to pregnancy.

The modern incarnation of the IUD is possibly safer and more effective than oral contraception. Chances of pregnancy on the IUD range from 0-1.1 per 100 woman-years of use, and they get lower with each year you use it (Prager and Darney 2007). That is far better than your chances on the pill.

The IUD suffers from a bad reputation, in part due to misinformation or misunderstanding on the part of medical providers. Harper et al (2008) surveyed 816 physicians, nurse practitioners and physician assistants who each serve more than 100 contraceptive patients per year in the California State family planning program. They found that 40% of medical providers didn’t offer IUDs to patients, 36% provided infrequent counseling. Further, 46% thought nulliparous women, and 39% thought postabortion women were good candidates for the IUDs. Younger physicians were more likely than older physicians to recommend the IUD (Harper et al. 2008), which suggests a generational gap due to the overinflated descriptions of the dangers of early IUDs.

So let’s go through the actual pros and cons of this form of contraception, so that over the course of the summer you can compare this information to what you’ll be learning about the pill.

Remember, I’m just an anthropologist who studies this stuff. I am not a medical doctor.

Danger danger! Or not

The biggest danger from an IUD is that it could perforate the uterus, or be expelled from it. And that can certainly be painful, reduce fertility, or get you pregnant when you think you are protected. So let’s look at how often this happens.

Prager and Darney (2007) wrote a review on the levonorgestrel IUD (hormone-releasing, like Mirena) in nulliparous (that means no parity, or no children) women. This is important because many still carry the misconception that nulliparous women shouldn’t use IUDs, because of an increased risk of perforation, infertility, pelvic inflammatory disease risk, and difficulty in placement.

There are notable differences between the parous (has had children) and nulliparous (no kids) uterus. The parous uterus is a little bigger, and the cervix dilates a bit more easily. However, it turns out that for the most part these differences are not great enough to produce any differences in side effects or danger to the woman using it.

Prager and Darney (2007) found six studies on perforation or expulsion rates for IUDs (some copper, some hormone-releasing, which are made of plastic and are flexible). They did not find enough data to support a link either way for nulliparity and perforation, because the studies they found had anywhere from zero to two nulliparous women in them. That said, the perforation rates for each study ranged from 0-1.3% in one study, and 2.6 out of 1000 in another (Prager and Darney 2007).

Expulsion rates do not seem to differ between parous and nulliparous women, and again, are very low for all women. The annual expulsion rate among cited studies was 0-4.2 per 100, 0-1.2% per year, and 0-0.2% per year (Prager and Darney 2007). The one important point they do make is that there is a very slightly increased risk of expulsion for lactating women – perhaps this is due to the oxytocin released during nipple stimulation, which could contract muscle?

The other concern sometimes mentioned is that of pelvic inflammatory disease. PID is an infection of the uterus and is usually associated with a sexually transmitted disease. PID can increase the risk of infertility. So for women who haven’t had a kid, but want to some day, the concern about getting PID can loom large.

However, Prager and Darney (2007) surveyed the literature and found that the only studies that support a link between PID and IUDs involves an IUD no longer on the market, or was associated with high-risk sexual behavior.

Hidden benefits

In some women, copper IUDs can increase menstruation. However, the hormone-releasing IUDs tend to decrease menstruation, and many women stop getting periods altogether. Hormone-releasing IUDs can be prescribed to women with menorrhagia, or pathologically heavy menstruation, too.

Prager and Darney (2007) describe a study in which hormone-releasing IUD users were compared to oral contraceptive users. These IUD users had less dysmenorrhea (painful periods), less spotting, fewer days of bleeding, fewer cycles. Further, 88% of the IUD users wanted to continue with that method of contraception after a year, compared to 68% of pill users, and this difference was statistically significant (p = 0.003).

Romer and Linsberger (2009) also looked at satisfaction with the hormone-releasing IUD in a sample of 8680 women across 18 countries: 95% were satisfied with their method of contraception.

The fine print

Insertion of the IUD can be a little more painful in a nulliparous woman, since her cervix has not dilated before. Also, a minority of women may spot for a while after insertion of the IUD… and by a while, I mean a few months. But once those few months of light spotting are over, they often don’t get a period again until removing the IUD. And of course, the IUD is not conducive to sudden desires to start the babymaking process: you will need to schedule its removal first.

However, with the number of women who are ambivalent at best about birth control pills, but do not want to use a barrier method, the IUD offers a lot in the way of safety, efficacy and ease of use.

Tuesday, June 21st 2011

This is the first in a new series at Context and Variation where I will attempt to be more concise. As I continue along the Summer of the Pill series I want to make sure I still put some attention on other topics within biological anthropology. C&V shorts allows me to share something I find cool, in half the words I usually do.

What would you do if you knew you had eighty years to live? What if you knew you only had forty?

Life history theory is the idea that the timing of major life events is adaptive. That is, when to be born, when to wean, when to grow, and when to reproduce are dependent on selection pressures in the environment. The most important concept within life history theory, then, is that of tradeoffs, because when you time these events is based off how you want to allocate your resources. In your environment, would it be best to grow right now? Should you grow under the care of your mother, or should you be independent? Is it time to have a child? How about your second, or third, or fourth child?

For this reason, many people study life history transitions, which means the critical yet variable period when people move from one state to another: from growing to reproductive cycling, from cycling to gestating, gestating to lactating, even lactating back to cycling. And much of what governs these transitions has to do with energy, because energy is finite: energy you use towards one purpose, like growing, cannot be used for another, like reproducing. This is especially true in humans because we permanently transition from allocating to growth to reproduction at puberty, unlike other species that keep growing throughout their reproductive years.

But energy isn’t the only factor that enters into our physiological decision-making: time is also important. And as I hinted in the first paragraph, if you have some sense that your time on this earth will be short or long, you might make different decisions about when to do what.

A few years ago, Walker et al (2006) looked at all the available data on growth and development in small-scale societies – that means foragers and agrarian populations. They found that girls with a later age at menarche – that is the first menstrual period – are shorter in stature. If we consider only energy, this makes no sense! The later you wait to start reproducing should mean you had more time to grow, so why did Walker et al (2006) find the opposite?

The answer is timing. It turns out that mortality rates tell us something about growth and development: the higher the mortality in a population, the earlier their age at menarche and age at first reproduction. So, the higher your chances of being offed at any given moment, the more likely you are to favor reproduction over growth so you can move ahead with the whole reproductive success thing. So, constraints on time and energy affect our physiology differently, and mean we may have to make different predictions about life history transitions that are dependent on human societies. Predation or access to health care impact mortality, but so do homicide or war.

In 2011, McIntyre and Kacerosky performed a similar analysis, only this time they compared small-scale societies with industrialized ones – industrialized societies are those that are more urban, technology-driven, with greater access to modern health care, like the USA. Their analysis of small-scale societies confirmed Walker et al’s (2006) results.

But McIntyre and Kacerosky (2011) found the opposite relationship in industrialized societies: there, the later you hit menarche, the taller you were. And this makes sense if we think we can assume most industrialized populations have lower mortality than the foragers: within the industrialized pops, those who had the time and energy to grow big by holding off on menarche, did.

McIntyre and Kacerosky (2011) are hesitant to be full adaptationists in their paper, which I appreciate. So, they offer two hypotheses and suggestions for future testing. The first hypothesis falls in line with the life history theory described in this post, though their focus is more on parental investment than mortality. But still, environment, and access to time and energy, set life history trajectories for different populations. However they are also careful to point out a nonadaptive hypothesis: it could be that variability in stature is decreasing as heritability is increasing, meaning we are hitting up against biological constraints for size.

Genes and environment interact to produce phenotype, and this is something most people remember from high school biology. But sometimes it’s nice to peek under the hood and learn a little something about the life history mechanisms that are set into motion by this interaction. Early life events, perhaps even life events of our mothers and grandmothers, start our life history trajectories. Then tradeoffs at certain important transition periods nudge us a little further one way or another for the rest of our lives.

References

McIntyre MH, & Kacerosky PM (2011). Age and size at maturity in women: a norm of reaction? American journal of human biology : the official journal of the Human Biology Council, 23 (3), 305-12 PMID: 21484909